Dental anxiety (DA) is defined as unreasonable apprehension toward dental procedures. About 4–20% of the worldwide adult population presents DA, with peaks of 30% in the younger population. Managing patients with dental anxiety and fear with a reliable and valid instrument is necessary to understand the multidimensional dimensions of dental fear. This work aimed to validate the Index of Dental Anxiety and Fear (IDAF-4C+) into Italian. Two hundred and eighty dental students attending an Italian university were enrolled. The IDAF-4C+ was translated by experts and a native English translator, blinded to the original version. The Modified Dental Anxiety Scale (MDAS) was used to assess the validity of IDAF-4C+. Spearman correlation coefficients and Exploratory Factorial Analysis (EFA) were used. Reliability was evaluated by Cronbach’s alpha. The reliability of the Italian version of IDAF-4C+ was good . Correlation between IDAF-4C+ and MDAS ranged between 0.42 to 0.68. From EFA, one factor explained 58.76% of the common variance. Women showed a higher level of dental fear. The Italian IDAF-4C+ is a valid and reliable tool to assess DA in any clinical context. This instrument allows for a proper understanding and management of DA, and therefore a better patient oral health-related quality of life and compliance with the dentist’s instructions. Dental anxiety (DA) is defined as unreasonable apprehension toward dental procedures or the whole context of the dental setting ,2. Its oAbout 36% of the adult population presents with a mild anxiety level for dental treatments . The preDiagnostic and Statistics Manual of Mental Disorder, Fifth Edition) and ICD-10  [DA is a multidimensional problem composed of two elements: anxiety and fear. The first is a cognitive factor, a future-oriented state responding to an anticipated threat, while the second is a contextual factor, a present-oriented emotional state responding to an immediate threat . In the evision) ,17,18,19Given the broad spectrum of severity, DA could be considered as a predictor of patient behaviors , a critiMany studies have investigated the etiology of dental anxiety in adults and the young, identifying direct and indirect causes . NegativFor the dental team, DA is also a source of stress. Patients with DA require additional time to implement dental care, complain of more discomfort and pain , and neeTherefore, assessment of DA is a part of the clinical evaluation of the patient’s condition. Knowing the magnitudes of DA may enhance the patient’s management , reduce Many psychometric scales have been developed to identify patients with DA and assign them a degree of severity. Recently, the Index of Dental Anxiety and Fear (IDAF-4C+) has been considered a valuable scale to assess DA in the adult population, and it has been translated into different languages ,33,34,35Associazione Nazionale Dentisti Italiani) research, over 17 million Italians have never made even one dental visit in their life. Furthermore, about 80% of Italians declare that they are afraid of the dentist, 20% are even terrified of them, to the point of reaching panic and anxiety attacks [According to Censis and ANDI  suggested that a cross-cultural adaptation process is necessary to maintain the original instrument content validity across different cultures, adapting language and meaning to the specific cultural context in which the tool will be used . This prThis cross-sectional study aimed to translate and validate IDAF-4C+ into Italian, testing its reliability and validity in comparison with the Modified Dental Anxiety Scale (MDAS) in a sample of undergraduate students, indicated by previous studies with subjects with a higher level of anxiety than the older population , more prThe original English version of the IDAF-4C+ was translated using a forward- and back-translation procedure ,44. FirsThe Index of Dental Anxiety and Fear (IDAF-4C+) is composed of three independent modules. The first module (IDAF-4C) contains eight items with responses, ranging on a 5-point Likert scale from “disagree” (score = 1) to “strongly agree” (score = 5) measuring both anxiety  and fear . This core module aims to measure four components of dental anxiety: cognitive, physiological, behavioral, and emotional.A total score was calculated for each participant by averaging responses to items. An IDAF-4C+ mean score ≤2.5 identified patients without fear or with a moderate fear; an IDAF-4C+ mean score ranging between 2.5 and 3.5 classified patients with moderate to high fear, and IDAF-4C+ mean score ≥3.5 identified patients with high to extreme fear ,34,35.The module IDAF-P aims to provide a screening of dental phobia diagnosis according to DSM-V-based criteria. It consists of five items with “yes” or “no” responses: three items to diagnose dental phobia, and the other two to provide a differential diagnosis from social phobia and panic disorder according to the DSM-V ,33. PatiThe third module, the stimulus module (IDAF-S), composed of ten items with five responses, ranging from “Not at all” (score = 1) to “Very much” (score = 5), aims to determine potentially anxiogenic stimuli present in a dental setting . The EngThe Modified Dental Anxiety Scale (MDAS) is a widely used measure of dental fear  and was The final Italian version of the IDAF-4C+ was administered to 280 students attending the University of Brescia. An online questionnaire was administered from 6 to 16 January 2021 through Google Forms. Students were recruited via email and were provided with information on the study. Participation in the questionnaire was voluntary, anonymous, and without any form of remuneration. This study did not fall under human research’s Italian law, and the Ethical Committee did not ask for specific approval.The first part of the questionnaire was the Italian translation of the IDAF-4C+ composed of 23 items. The second part was the Italian version of MDAS, already validated by Facco et al., (2015) . FinallyThe sample size was determined a priori .Exploratory factor analysis (EFA) with principal axis factoring, promax rotation (k = 4), and extraction of factors based on eigenvalues higher than one was used to verify if there were more than one underlying construct within the measure. Prevalence of dental anxiety was determined for IDAF-4C+ and MDAS using the pre-defined cut-points for both scales. The U Mann–Whitney test was used to compare IDAF-4C+ and MDAS scores between males and females. Associations between IDAF-4C+ and MDAS scores were evaluated through Spearman’s correlation coefficients. Cronbach’s alpha was calculated to assess the reliability of the scales according to Nunnally parameters .Two hundred and thirty-two students were included in the study (response rate = 82.86%). Participants’ mean age was 23 years (SD ± 3.1 years), and most were female . Respondents’ characteristics are reported in From the exploratory factor analysis of the IDAF-4C+, it emerged that one factor explained 58.76% of the common variance .Items in IDAF-4C+ reported factor loadings ranging from 0.65 to 0.88, which confirms the strong correlation of each item with a latent construct. IDAF-4C+ and MDAS and their subscales were correlated with coefficients ranging from 0.29 to 0.97 .low/moderate fear = 46.15%, menlow/moderate fear = 36.84%; womenhigh fear = 5.77%, menhigh fear = 1.32%), though without any statistically significant difference  of participants had no dental fear, 43.10% (n = 100) had low/moderate dental fear, and 4.31% (n = 10) had high dental fear. Higher percentages of women showed low/moderate or high dental fear   .None of the participants showed dental phobia as previously defined .Five male participants answered “yes” to any of the IDAF-4P items. In contrast, women tended to report higher scores for IDAF-4S, although no statistically significant differences emerged .Cronbach’s alpha was 0.88 for IDAF-4C+ and 0.87 for MDAS.Dental anxiety is a complex situation characterized by an emotional response to stimuli or experiences associated with dental treatments , which rPatients with a high DA level can exacerbate discomfort associated with dental care, amplifying pain and discomfort before, during, and after the dental treatment . Vice veProper management of patients with DA may help clinicians reduce stress and negative consequences and possibly transform the vicious circle  into a vIDAF-4C+ may be a helpful tool for early detection of DA by dental professionals because it may assure better treatment outcomes . From ouAs demonstrated by previous studies, dental anxiety and fear were more common among women than men in IDAF-4C+ and MDAS, although without statistically significant differences ,50.From the comparison between IDAF-4C+ and MDAS classifications, some relevant differences emerged. The number of participants with no dental fear was higher with IDAF-4C+ (92.67%) than with MDAS (52.59%). In contrast, IDAF-4C+ reported a lower percentage of participants with moderate fear (3.88%), while MDAS registered higher rates (43.10%) of participants with low/moderate dental fear. This relevant difference between the two measures could be due to the different cut-points used, which also emerged in Tolvanen et al., (2017), or could be the results of the different dimensions captured by the two scores . MDAS map < 0.001) and MDAS and physiological  and emotional  components. This finding is in line with previous studies [Strong association was reported between MDAS and IDAF-4C+ scores . Hawthorne effect and bias due to self-reported assessment could also be present. Moreover, possible respondents with a higher level of DA could have decided not to participate in the survey.The IDAF-4C+ Italian version is a valid and reliable tool to determine the presence and level of dental anxiety. It will help clinicians identify patients who suffer from dental anxiety, fear, or phobia in a more standardized way, evaluating dental anxiety, fear, and dental phobia with only one tool. In a country where more than 80% of patients have odontophobia, using a validated and cross-cultural adapted tool may encourage patients to start collaborative behaviors with their dentists.For future research, it will be important to test the reliability and validity of this instrument in the specific categories of patients such as those who require more invasive dental surgery.


In vitro experiments suggested that LINC01278 promoted the proliferation of leukemic cells and inhibited leukemic cell apoptosis by targeting the inhibition of miR-500b-3p in cALL, and LINC01278 may be a biological target for the treatment of cALL in the future.Childhood acute lymphoblastic leukemia (cALL) still represents a major cause of disease-related death in children. This study aimed to explore the prognostic value of long non-coding RNAs (lncRNAs) in cALL. We downloaded lncRNA expression profiles from the TARGET and GEO databases. Univariate, least absolute shrinkage and selection operator (LASSO) and multivariate Cox regression analyses were applied to identify lncRNA-based signatures. We identified an eight-lncRNA signature , which separated the patients into two groups with significantly different overall survival rates. A nomogram based on the signature, BCR ABL1 status and white blood cell count at diagnosis was developed and showed good accuracy for predicting the 3-, 5- and 7-year survival probability of cALL patients. The C-index values of the nomogram in the training and internal validation set reached 0.8  and 0.806 , respectively. The nomogram proposed in this study objectively and accurately predicted the prognosis of cALL.  Acute leukemia is the most common childhood malignant tumor. And there would be one patient in every three children who has it in the developed countries and nearly 50% in developing countries . The comLong non-coding RNAs (lncRNAs) are RNAs with a length of more than 200 nucleotides . AlthougcALL is a complex disease composed of many subtypes with unique somatic genetic changes, including aneuploidy, chromosomal rearrangements, and point mutations . To dateTo identify lncRNA associated with prognosis and guide clinical applications in cALL, we combined RNA-seq data and clinical information from 426 B-ALL patients to create a nomogram with an 8-lncRNA signature.A matrix was downloaded from the TARGET database. 532 participants in total with cALL had lncRNA probe expression; after excluding 76 peripheral blood sources and 30 patients older than 15 years, 426 bone marrow-derived patients remained. Patients with cALL in the TARGET cohorts (n=426) were separated into training (n=300) and validation (n=126) sets, and their clinical features are presented in A total of 1280 lncRNAs were applied to univariate Cox analysis, and 165 lncRNAs with P < 0.01 were filtered out and applied to subsequent analysis . Then, 8The prognostic variables were determined by univariate Cox regression analysis, and the candidate variables with P < 0.2 in univariate analysis were contained in multivariate COX regression analysis. . Next, tFurthermore, the predictive values in the calibration curve were consistent with observed values when thinking the probabilities of 3-year, 5-year, and 7-year OS . The AUC3/mcL at the first diagnosis have significantly worse OS than those with a WBC count less than 200 x103/mcL , patients were separated into groups of those with a high-signature score (n = 63) and a low-signature score (n = 63) with the median signature score as the cutoff point . The KapIn addition, the above validation process was carried out on the entire TARGET-ALL set (n=426) and revealed a good result .To explore whether the 8-lncRNA signatures are equally applicable to adult ALL, we conducted the analysis process in the GSE34861 cohort. Taking the median score as the dividing point, participants were separated into two groups: high signature group (n = 92) and low signature group (n = 92). . The AUCFirst of all, we used Pearson correlation coefficient > 0.90 and P < 0.001 as cutoff points to screen the genes co-expressed with lncRNA. Then, we used the exp matrix composed of the mentioned 8 lncRNAs and 4985 genes as the input files. To create a scale-free system, the soft threshold beta to 9 was set . Genes wAfter analysis, we found that LINC01278, AC114490.1, AL132639.3, and TTC28.AS1 were all in the turquoise module, which had a strong positive correlation with first event of relapse , BCR ABL1 status , signature score , and WBC count at diagnosis  –6D. FurtAdditionally, LINC00630, HDAC2-AS2, and AL356599.1 were together in the brown module, which had a positive correlation with WBC count at diagnosis , first event of relapse , BCR ABL1 status , and survival time  –5D. Funcin vitro experiments, because WGCNA suggested that it was closely related to the expression of multiple oncogenes, and enrichment analysis showed that the genes significantly related to LINC01278 were enriched in lymphocyte proliferation and differentiation. Predicted by online websites such as starBase2.0 [http://starbase.sysu.edu.cn/) and miRcode (http://www.mircode.org/), we found multiple binding sites between LINC01278 and miR-500b-3p, which suggests that LINC01278 may play a role by acting on miR-500b-3p. In the CCRF-CEM cell model with LINC01278 knocked down, we found that the well-known apoptosis-promoting molecules BAX, Caspase1, and Cytc were more highly expressed in the group with miR-500b-3p than the NC group according to qRT-PCR and Western blot assays (P<0.05). Additionally, after the transfection of miR-500b-3p, flow cytometry analysis indicated that the fractions of cells in early apoptosis late apoptosis and total apoptosis were significantly higher (P<0.05). These results suggested that LINC01278 may inhibit apoptosis and increase the proliferation of cALL cells via miR-500b-3p.To further clarify the mechanism of how the 8 lncRNAs affect the survival of cALL patients, LINC01278 was chosen to study the mechanism using rBase2.0   is ubiquitously expressed in bone marrow, lymph nodes and 25 other tissues and is considered a biomarker for various cancers, such as non-small-cell lung cancer  and coloin vitro and in vivo. Xi et al. [in vivo experiments showed that LINC01278 can enhance the proliferation of leukemic cells and inhibit leukemic cell apoptosis by the inhibition of miR-500b-3p. Our study reveals for the first time the role of LINC01278 in cALL, and LINC01278 may be a biological target for the treatment of cALL in the future. LncRNA-based signatures are a novel tool that provides simple and accurate predictions of clinical results.Huang et al.  identifii et al.  demonstrNomograms have been generated for most cancer types. In the prognosis evaluation of various cancers, nomogram is in higher rate of accurate and convenient than the normal staging system –40. TherIn conclusion, the model we have developed can firmly and predict the prognosis of patients in accurate. Our work also reveals that LINC01278 can enhance the proliferation of leukemic cells and inhibit leukemic cell apoptosis by targeting inhibition of miR-500b-3p in cALL, and LINC01278 may be a biological target for the treatment of cALL in the future.https://ocg.cancer.gov/) and GEO (https://www.ncbi.nlm.nih.gov/gds/) database.LncRNA and mRNA RNAseq data and clinical parameters associated with cALL patients were from the NCI TARGET database (TM). All cells were kept at 37° C in 5% CO2 in MCO-18AC  supplemented with 1% penicillin-streptomycin  solution including DMEM  and 10% FBS .The human CCRF-CEM cell line was from the Typical Culture Preservation Commission Cell Bank, Chinese Academy of Sciences. CCRF-CEM is a cALL cell line in the ATCC cell bank  of LINC01278 were constructed by GenePharma . Cells were transfected via Lipofectamine 2000 . After 48 h of siRNA knockdown transfection, expression was analyzed by qRT-PCR.The methods of RNA extraction, reverse transcription and amplification follow those in our previous study . SupplemProtein from cells was extracted by rotor and radio immunoprecipitation assay (RIPA) lysis buffer. Equal amounts of protein were divided by SDS-PAGE in a 12% gel and transferred to a nitrocellulose membrane. The proteins were analyzed by an optimized chemiluminescence system based on the manufacturer's instructions. We incubated the membranes overnight with the primary antibodies: anti-Caspase 1 ; anti-CytoC ; anti-Bax ; anti-GAPDH ; and anti-Bcl-2 .FITC-labeled annexin V staining  was used to determine phosphatidylserine externalization to indicate early apoptosis according to the manufacturer’s instructions.4 cells per well. CCRF-CEM cell proliferation was evaluated via the CCK-8 assay. After 24, 48, and 72 h, 10 μL of CCK-8 reagent  was used for the cells and then the cells would be incubated at 37° C for 1 h. An automatic microtiter plate reader was set to zero bin accordance with the control wells. The absorbance (A) of each well was assessed at a wavelength of 450 nm.CCRF-CEM cells in the logarithmic growth phase were seeded in 96-well microplates with 1 × 10The enrichment analysis of GO and KEGG functions was realized through the package org.Hs.eg.db and cluster Profiler in R software.Since the datasets (TARGET and GEO) are available in public, ethical approval was not required.Supplementary FiguresSupplementary Table 1


Carbon nano-onions (CNOs) were successfully synthesized by employing the flame pyrolysis (FP) method, using flaxseed oil as a carbon source. The alcohol reduction method was used to prepare Pd/CNOs and Pd-Sn/CNOs electro-catalysts, with ethylene glycol as the solvent and reduction agent. The metal-nanoparticles were supported on the CNO surface without adjusting the pH of the solution. High-resolution transmission electron microscopy (HRTEM) images reveal CNOs with concentric graphite ring morphology, and also PdSn nanoparticles supported on the CNOs. X-ray diffractometry (XRD) patterns confirm that CNOs are amorphous and show the characteristic diffraction peaks of Pd. There is a shifting of Pd diffraction peaks to lower angles upon the addition of Sn compared to Pd/CNOs. X-ray photoelectron spectroscopy (XPS) results also confirm the doping of Pd with Sn to form a PdSn alloy. Fourier transform infrared spectroscopy (FTIR) displays oxygen, hydroxyl, carboxyl, and carbonyl, which facilitates the dispersion of Pd and Sn nanoparticles. Raman spectrum displays two prominent peaks of carbonaceous materials which correspond to the D and G bands. The Pd-Sn/CNOs electro-catalyst demonstrates improved electro-oxidation of methanol and ethanol performance compared to Pd/CNOs and commercial Pd/C electro-catalysts under alkaline conditions. With the growing energy crisis and environmental pollution over the last few decades, fuel cell technology has gained more attention . A fuel 2) or palladium-based bimetallic or multimetallic alloy nanostructures  increases its electro-catalytic activity compared with its Pd counterpart [2), demonstrating a reliable approach to improve the electro-catalytic activity of DAFCs [2 is a promising candidate because it supplies abundant OH species at the interface sites of the catalyst surface to remove CO intermediates [Ethanol and methanol are the most utilized alcohols in DAFCs, due to low cost, easy handling and storage, and high energy density . Howevernterpart ,10. For mediates . FurtherExploring robust support materials is another feasible strategy to facilitate the alcohol oxidation reaction (AOR) performance of Pd-based catalysts; this strategy further improves the stability and utilization efficiency of metals . DiffereCNOs are a recent addition to the nanostructured carbon materials family; they are spherical particles with concentric shells of graphitic carbon that are typically 4–25 nm in diameter . Due to 3OH) 99.8%, Nafion 117 solution, palladium (II) chloride (PdCl2) 59–60%, tin(II) chloride (SnCl2) 98%, and potassium bromide (KBr) ˃99.9% were purchased from Sigma Aldrich . Ethanol (C2H5OH) ˃99.9%, sulphuric acid (H2SO4) 95.0–97.0%, hydrochloric acid (HCl) 24–26%, and sodium hydroxide pellets (NaOH) 98% were supplied by Honeywell  and SRL Chemicals . Potassium hydroxide pellets (KOH) 85% were obtained from Merck Chemicals . Flaxseed oil and wick were purchased from Checkers and Pick n Pay, respectively . All reagents were of analytical grade and used as received without further purification. De-ionized water was used throughout to prepare solutions.Methanol  for 6 h .3 and 2 M H2SO4 (1:3) in a 250 mL round-bottom flask. The reaction mixture was refluxed for 4 h to introduce carboxylic acid functional groups. The functionalized carbon nanomaterial was filtered and subsequently placed in a vacuum oven at 60 °C overnight to dry [A 1.00 g amount of CNOs was dispersed in a 160 mL mixture of 2 M HNOt to dry .2, and 42 mg SnCl2 were dispersed in 75 mL of ethylene glycol solution and ultrasonicated for 30 min. The mixture was refluxed for 4 h under magnetic stirring to allow for the reduction of the metal precursors. The resulting black suspension was filtered, washed with deionized water, and dried overnight at 60 °C to obtain Pd/CNO and Pd-Sn/CNO electro-catalysts.A 1.00 g amount of CNOs, 83 mg PdCl−1, the samples were scanned as solids. Raman spectra were recorded with a T64000 series II triple spectrometer system from HORIBA scientific, Jobin Yvon Technology, using Lab Spec 5 software and 514.3 nm laser line of a rational Innova® 70C arrangement Ar + laser (spot estimate ~2 μm) with a determination of 2 cm−1 in the range 200–1800 cm−1. PANayltical X’Pert Pro powder diffractometer instrument was used to obtain the Powder X-ray diffraction  measurements of CNO, Pd/CNO, and Pd-Sn/CNO nanomaterials. Measurements were performed in the 2θ range from 5 to 90° with Cu Kα radiation (λ = 0.15405 nm) at 40 kV and 40 mA operational conditions. Brunauer–Emmett–Teller  was used for surface area analysis. Inductively coupled plasma ICap 6000 series  was used to evaluate the actual metal loading in electro-catalysts. X-ray photoelectron spectroscopy  (XPS) was utilized to study the elemental composition and electronic state of palladium and tin within the carbon nano-onions using an Al (monochromatic) anode, furnished with a charge neutralizer.A Jeol JEM-2100F Electron Microscope instrument equipped with a LaB6 source was used to perform high-resolution transmission electron microscopic  studies at an increasing speed voltage of 200 kV was conducted to study the internal morphology of synthesized nanomaterials. ZEISS-AURIGA field emissions scanning electron microscopy , 3 kV acceleration voltage was used to investigate the external morphology of the prepared nanomaterials. Fourier transform infrared spectroscopy  was performed using Model PerkinElmer Spectrum 100 to measure the infrared spectra of the carbon nano-onion supports and Pd/CNO and Pd-Sn/CNO electro-catalysts. In the frequency range of 500–4000 cmA 10 mg amount of as-synthesized electro-catalysts was dispersed in 2 mL ethanol with 5 µL of Nafion solution to make the catalyst ink. The catalyst ink solution was sonicated for 15 min before 15 µL was drop-coated on a dried pre-treated glassy carbon electrode (GCE). The GCE was polished on Micro cloth TM  with 1.0, 0.3, and 0.05 µm alumina slurries in decreasing order prior to drop coating. This was sonicated with double-distilled water to remove free particles from the micro cloth.−2. The alkaline electrolyte solution was purged with argon 15 min before the electrochemical experiments. The chronoamperometry experiment was conducted while the solution was agitated under magnetic stirring at 50 rpm to keep the solution near the electrode homogeneous. All the results were compared to a commercial 10 wt% Pd/C electro-catalyst that was studied under the same conditions.Electrochemical investigations were conducted using Ivium Technologies Compactstat.h standard and a three-electrode system. The potentials of the working electrode were determined using the reference (Ag/AgCl) and counter (Pt wire) electrodes, which were both saturated with 3 M NaCl. During the electrochemical measurements, the working surface area of the modified GCE was 0.07 cm2 hybridized carbon bonds, is responsible for the observed D-band. Dangling bonds, sp3 bonding, vacancies, and other carbon rings resulting from structural rearrangement all contribute to this [−1 is due to the existence of more sp3 hybridized carbons close to those found in the diamond-like amorphous material [2 carbon bonds are attributed to the presence of this peak, which represents the order of graphitic carbons in the structural matrix of CNOs [D/IG) is used to quantify the degree of graphitization of CNOs produced. The degree of disorder in the form of sp3 hybridized carbons and the presence of shorter graphitic fragments are directly linked to the disorder density ratio. The ID/IG value of CNOs is 0.85, denoting a high degree of graphitization within the CNO matrix. Meanwhile, the ratios of the Pd/CNO and Pd-Sn/CNO electro-catalysts were found to be 0.96 and 0.99, respectively. The higher ID/IG values of the electro-catalysts compared to those of the CNO supports indicate that the incorporation of Pd and Sn into the CNOs caused defects in the CNO structure and lattice symmetry [The Raman spectra of carbon nano-onions (CNOs), Pd/CNOs, and Pd-Sn/CNOs are depicted in  to this ,24. The material . The G-b of CNOs . The ratsymmetry .2. The corresponding particle size histograms in The morphology of the as-prepared carbon nano-onions (CNOs) was investigated using HR-TEM; the micrographs are presented in Field emission scanning electron microscopy (FESEM) images of carbon nano-onions supports and Pd/CNO and Pd-Sn/CNO electro-catalysts are depicted in −1 and 3445 cm−1, ascribed to the OH vibrational stretch of the carboxylic group on the surface. Generally, the OH peak between 3000 and 3500 cm−1 is a broad peak. However, in this case, the peak is split into two; this is associated with the presence of alcohol O–H groups and water on the CNO surface [−1 and 1085 cm−1 correspond to the aliphatic –CH and –CH2 groups, respectively. The vibration at 1636 cm−1 represents the C=O carbonyl group. The vibration at 1403 cm−1 corresponds to C=C stretching due to aromatic rings or an alkene functional group. The presence of carboxylic and hydroxyl groups on the CNO surface is confirmed by these peaks. These functional groups are responsible for the high hydrophilicity and dispersibility of the as-synthesized sample. The FTIR spectra of the Pd/CNO and Pd-Sn/CNO electro-catalysts are consistent with the results observed on the CNO spectrum, with the same functional groups observed. The attachment of the metal nanoparticles is promoted by the oxygen-containing species on the CNO surface [The existence of functional groups in the prepared CNOs, Pd/CNOs, and Pd-Sn/CNOs was evaluated by FTIR analysis . The CNO surface ,32.XRD was performed to evaluate the crystal structure and phase purity of the CNOs, Pd/CNOs, and Pd-Sn/CNOs. The average particle size of palladium in the electro-catalysts was calculated from the XRD peak of Pd (111) using the Debye-Scherer equation:he X-ray .The lattice parameters of the electro-catalysts were calculated from XRD data using the equation below:flection .XPS was used to evaluate the surface chemistry and electronic structures of the CNO series reported in 5/2 and 3d3/2 spin-orbit components, as labelled in the figure. The best fit to the experimental data was obtained by adding two spin-orbit doublets  and a Shirley-type background. The binding energy of these two components makes it possible to ascribe them to Pd0+ and Pd2+ oxidation states, which are appended to the figure [e figure . The fit5/2 and 3d3/2 spin-orbit components, as labelled in the figure. Each of these two has a low-intensity shoulder on the low binding energy side of the main peak. The core level was therefore fitted with two spin-orbit components  and a Shirley background [+ and 4+ oxidation states for Sn ions in this sample, located at 485.51 eV and 487.66 eV, respectively, for 3d5/2. The comparison of the intensities shows that ~95% of the spectral intensity in this core level derives from the 4+ oxidation state [XPS was also used to study the oxidation states of Sn and Pd; ckground . The binon state .The O 1s core level for the CNO samples is reported in Finally, 2 and SnCl2) were reduced to their respective metallic states using ethylene glycol. It is worth mentioning that, logically, the loading of Pd/CNOs should be higher than Pd-Sn/CNOs. However, this is not so because in Pd-Sn/CNOs, Pd was anchored on CNO supports and also in the Pd-Sn alloy, compared to Pd/CNOs where the anchoring site was only from CNOs.ICP-OES analysis was performed to determine the actual metal loading of the electro-catalysts. 2 adsorption–desorption isotherms and BJH desorption pore-size distribution are presented in BET was performed to evaluate the surface area of the carbon nano-onion (CNO) supports and Pd/CNO and Pd-Sn/CNO electro-catalysts. The results, tabulated in a table below, indicate that the surface area decreased as the surface of the CNOs was modified with palladium, and further decreased after the addition of tin nanoparticles to the Pd/CNO electro-catalyst. Notably, the palladium and tin electro-catalysts reveal lower surface areas compared to the CNO supports, indicating coverage of pores by the Pd and Sn nanoparticles. The pore-size distribution (PSD) was investigated using the Barrett, Joyner, and Halenda (BJH) technique applied to the desorption branch . The PSD- adsorption peak was observed from −0.8 V to 0.4 V and a PdO reduction peak was observed from 0.4 V to −0.8 V. At lower potentials, the Pd-Sn/CNO electro-catalysts possess the highest oxygenated species reduction, facilitating alcohol oxidation [−2), and l is the palladium loading (g cm−2).xidation . The elexidation :(3)EASA=2 mg−1, 168.32 cm2 mg−1, and 276.12 cm2 mg−1, respectively. The CV currents were normalized to the electrode surface area using these values. An enlarged EASA signifies the presence of more electrochemically active sites. The Pd-Sn/CNO electro-catalyst shows the highest EASA value, compared to the Pd/CNO and standard Pd/C electro-catalysts. This is due to the homogenous dispersion of PdSn metallic particles over the carbon nano-onion supports, indicating a strong metal–support interaction.The EASA values for the Pd/C, Pd/CNOs, and Pd-Sn/CNOs were found to be 142.94 cm−) in alkaline medium and provided by PdSn alloy. In an alkaline medium, the backward peak is smaller than the forward peak. This is because, in an alkaline medium, the removal of adsorbed carbonaceous species is easier due to the availability of oxygen-containing species (hydroxyl and carbonyl carbon), which allow faster methanol oxidation [Two distinct forward and backward current peaks characterize alcohol oxidation reactions. The oxidation reaction is represented by the forward peak due to electro-oxidation of newly chemisorbed species resulting from adsorbed alcohol molecules. The elimination of intermediates that were only partially oxidized in the forward scan is represented by the backward peak. The catalytic activity for the electro-oxidation reactions of alcohol fuels is measured by the size of the forward peak ,49,50. Axidation .3OH solution at different scan rates. As depicted in The Pd-Sn/CNO electro-catalyst outperformed the other two electro-catalysts as indicated by high current density, low potential, and stability. EIS was used to assess the catalytic efficiency of a Pd-Sn/CNO electro-catalyst for electro-oxidation of methanol in an alkaline electrolyte. The Nyquist impedance spectra of each anode electro-catalyst was recorded in the frequency range from 0.005 Hz to 1000 kHz B. The el−1. To evaluate the electrochemical processes occurring at the modified glassy carbon electrode, the effect of scan rate on current density was investigated (adsorption or diffusion). As expected, the anodic peak current density is directly proportional to the square root of the scan rate. As the peak current density increases with the scan rate, the peak potential is drifting to more extreme potentials. The development of poisonous intermediates during the oxidation of ethanol may be linked to this change in potentials [tentials . Despitetentials .3CH2OH shown in y-axis of the CA curves was normalized to convert it into a relative current (%)  measurements were taken for 2000 s at 0.5 V in a solution of 1 M KOH + 1 M CHrent (%)  in orderHighly stable and electro-active carbon nano-onions supporting a palladium and tin alloy (Pd-Sn/CNOs) were prepared successfully. Carbon nano-onions were prepared by the flame pyrolysis method, using flaxseed oil as a carbon source. Thus, the PdSn alloy could be utilized at a smaller rate to counter the metal cost. Carbon nano-onions reduced the utilization of Pd and Sn while enhancing the capability of the electro-catalyst. Pd-Sn/CNOs with a high amount of alloying between Pd and Sn NPs demonstrate improved electro-catalytic activity. Chronoamperometry results also showed that the Pd-Sn/CNO electro-catalyst exhibited improved electro-catalytic stability and lower poisoning rate towards methanol and ethanol oxidation compared to the other electro-catalysts. The results obtained from EIS are in good agreement with the CV and CA results. The findings revealed that when particle dispersion and particle size are adjusted on a CNO support, the metal loading effect dominates electrochemical activity. The source of the CNO and the method of metal loading play a role in achieving high mass loading with regulated particle size and high dispersion. It was further revealed that Pd-Sn/CNO nanocomposites exhibit better electro-catalytic activity towards methanol and ethanol oxidation than Pd/CNOs and Pd/C in alkaline conditions and have great potential for applications in other electro-catalytic reactions.


Immune checkpoint inhibitors plus radiotherapy is emerging as a new strategy in non-small cell lung cancer patients. There were biological basis for this combination, the aim of this review of the literature was to explore clinical trials using this combination and to summarize the results of published studies with meta-analysis. The results of our systematic review should encourage the research community to further investigate the relationship between immune checkpoint inhibitors and radiotherapy, which may improve oncological outcomes. p = 0.0003) and 0.85 , respectively. Furthermore, there was a statistically significant benefit on 1- and 3-year progression-free survival  and RR 0.82 , respectively). Conclusions: In patients with advanced or metastatic NSCLC, combination ICI-RT increases 1- and 3-year OS and progression-free survival compared to ICI or RT alone.Background: Immune checkpoint inhibitors (ICI) plus radiotherapy (RT) have been suggested as an emerging combination in non-small cell lung cancer (NSCLC) patients. However, little is known about the magnitude of its benefits and potential clinical predictors. Objective: To assess the effects of this combination on the increase in overall and progression-free survival. Data sources: The MEDLINE and CANCERLIT (1970–2020) electronic databases were searched, and the reference lists of included studies were manually searched. Study selection: Studies were included if they were comparative studies between combination ICI-RT and ICI or RT alone in advanced or metastatic NSCLC patients. Overall survival (OS) was analyzed according to the treatment strategy. Data extraction: Data on population, intervention, and outcomes were extracted from each study, in accordance with the intention-to-treat method, by two independent observers and combined using the DerSimonian method and Laird method. Results: Compared to ICI or RT alone, ICI-RT significantly increased the 1-year and 3-year OS RR by 0.75 (95% CI 0.64–0.88;  Tumor immunotherapy has been an amazing leap forward in cancer therapy. In particular, the introduction of immune checkpoint inhibitors into clinical practice has improved outcomes of lung cancer treatment . This neThe interaction between radiation and the immune response has been experimentally proven. Radiation induces infiltration of a wide range of leukocytes: effector T cells, natural killer (NK) cells, regulatory T cells (Tregs), and CD11b-positive (CD11b+) cells, such as myeloid-derived suppressor cells (MDSCs) and tumor-associated macrophages (TAMs) . As descThe efforts for immunomodulation to increase the effects of ICI-based treatment for advanced NSCLC favored the combination of ICI with RT in clinical practice  before iThe results of published comparative studies remain inconsistent , and an overall assessment of the treatment effect on survival is difficult to evaluate despite being clinically notable. The improvement in survival remains a major issue in the management of advanced or metastatic NSCLC. We aimed to summarize the available observational and randomized evidence in one updated systematic review and meta-analysis. Our objectives were to establish the effects of the ICI-RT association in terms of 1- and 3-year overall survival and 1-year and 3-year progression-free survival and to explore and explain the presence of heterogeneity among studies.The search syntax of keywords was: “immune checkpoint inhibitor” OR “nivolumab” OR “pembrolizumab” OR “atezolizumab” OR “durvalumab” AND “Non-Small Cell Lung Cancer;” “immune checkpoint inhibitor” AND “Radiotherapy” AND “Lung Cancer;” “immune checkpoint inhibitor“ AND “Randomized Controlled Trial” OR “Comparative study.” Pertinent records were retrieved from MEDLINE, EMBASE, OVID, and Web of Science, and Scopus databases, while the timeframe applied was from the time of inception to 2020. No filters were applied regarding languages or countries to avoid language bias. To identify extra records, the computer search was supplemented with hand searches of reference lists for all available review articles, primary studies, meeting abstracts and bibliographies of books to identify additional studies not found in the computer search.For grey literature and to avoid publication bias, Google Scholar were searched to retrieve unpublished relevant comparative studies. The total results from each online database and extra sources were recorded in a flow chart diagram of PRISMA. Finally, the number of results from each database was recorded. The final inclusion of articles was determined by consensus between 2 authors (F.F. and J.G.); discrepancies among reviewers were infrequent  and were solved by discussion.All studies comparing survival outcomes between associations of ICI-RT and ICI or RT alone in patients with advanced NSCLC were deemed eligible for this meta-analysis. Because randomized controlled trials regarding this topic are rarely conducted, retrospective studies and nationwide population-based studies, such as the National Cancer Database (NCDB) study, were also included if they reported the survival outcomes.p-value of the significance of the estimates. Otherwise, the studies had to show the survival curves with the number in each group to estimate the RR.The inclusion criteria were as follows: (1) the study enrolled a case group of patients treated with ICI and RT and a comparator group of patients treated with ICI alone; (2) the outcomes were compared in terms of OS; and (3) sufficient information was available to estimate the risk ratio (RR) and 95% confidence interval (CI). The eligible studies had to provide RR or crude data and corresponding standard errors (SE), variance, CI, or The exclusion criteria were as follows: (1) studies analyzed fewer than 20 patients; (2) a single-arm design that did not have a control group; (3) case reports or only abstracts from conference meetings that were not published as original articles; and (4) more than 1 report by the same author or working group within the same study period.Studies were first reviewed using a list of predefined, pertinent aspects concerning the characteristics of patients and treatments. The quality of each fully published trial was assessed. For observational cohort studies, we used the nine-star Newcastle-Ottawa Scale (NOS) , which iFor RCTs, we used the Cochrane Collaboration’s risk of bias tool . This toχ2 test [2 statistic [The crude rates of 1-year and 3-year overall survival were assessed as measures of the treatment’s effect. If these data were not available , we usedχ2 test  and the tatistic .The number needed to treat (NNT) for benefit, which derives from the inverse of the absolute difference in risk among treatment groups (1/RD), was also used as a measure of the benefits of treatment. We, in turn, excluded each study to ensure that no single study would be solely responsible for the significance of any result of the robust analysis. All these analyses were computed using Revman 5.3 .We performed several sensitivity analyses to help address the heterogeneity of the study design and patient populations. Because National Cancer Database studies were present, we conducted separate analyses according to the source of data (RCTs vs. other studies) and study quality. We also analyzed studies according to comparators  and baseline stage patients . Finally, other study-level characteristics (such as PD-L1 status and histology) were prespecified for the assessment of heterogeneity, using subgroup analysis.p < 0.05 using ProMeta software v.3.0 . Furthermore, we used the nonparametric approach reported by Combescure et al. [https://github.com/atontini/ICI-RT-NSCLC (accessed on 20 March 2021).We assessed the potential for publication bias through formal tests  . All stae et al.  to assesThere was no funding source for this study. The corresponding author had full access to all the data in the study and had the final responsibility for the decision to submit it for publication.In total, 1276 records were initially retrieved from the computerized database search and manually checked. After the removal of duplicate records, 714 records were considered for review of the title and abstract. Of these, 82 records were selected as seemingly relevant publications. After assessment of the full text for eligibility, 68 records were further excluded because they were single-arm observation studies. Finally, six studies were included in the pooled analysis .The main features of the six trials included in this meta-analysis are shown in For the Bates et al. study , we chosp = 0.0003) (NNT = 11). Similar results were obtained when a fixed-effects model was used ; p < 0.00001). Using robust analysis, the pooled estimate of the treatment effect was significant. In particular, robust analyses showed that evaluation of the five studies remaining after omission of the largest trial by Bates et al. [p < 0.0001) (NNT = 11). In the subgroup of studies comparing ICI-RT vs. ICI alone (4151 patients), the addition of RT to immunotherapy was associated with a statistically significant benefit in 1-year OS  p = 0.04) (NNT = 7). Analyzing two studies [p = 0.006) (NNT = 12). In the subgroup of studies enrolling metastatic NSCLC, ICI-RT was associated with a statistically significant 1-year OS benefit  p = 0.02) (NNT = 9).The effect of adding radiotherapy to immunotherapy on 1-year overall survival  is shown in s et al.  did not  studies  with locp = 0.0006) (NNT = 10). Similar results were obtained when a fixed effect model used RR 0.61 . This effect on 3-year overall survival depended on the study. In the subgroup of studies comparing ICI-RT vs. RT alone (4284 patients), treatment with ICI-RT was associated with a statistically significant benefit in 3-year OS  p < 0.00001) (NNT = 7). In the subgroup of studies comparing ICI-RT vs. ICI alone (4284 patients), ICI-RT was associated with a marginally statistically significant benefit in 3-year OS  p = 0.04) (NNT = 12). Analyzing two studies [p = 0.0001) (NNT = 7). In the subgroup of studies enrolling metastatic NSCLC, treatment with ICI-RT was associated with a significant benefit in 3-year OS  p = 0.01) (NNT = 11).Three-year overall survival was reported in six studies (8435 patients: 3298 deaths). Data from two RCTs  were rep studies ,17 with OS curves for the ICI-RT association were extracted from the studies, and the summary survival curves are shown in p = 0.0003) (NNT = 4). Similar results were obtained when a fixed-effects model was used. This effect differed across studies. Only one study compared ICI-RT vs. RT alone [p < 0.000001) (NNT = 4). In the subgroup of studies comparing ICI-RT vs. ICI alone (245 patients), the association of RT with immunotherapy was associated with a statistically significant benefit in 1-year PFS  p = 0.01). Two studies [p = 0.001) (NNT = 4). Two studies enrolled metastatic NSCLC [p = 0.11).The effect of ICI-RT on 1-year progression-free survival  is shown in RT alone ,15  (NNT = 6). Similar results were obtained when a fixed-effects model was used (RR 0.75 (95% CI 0.70–0.81) p < 0.00001). In all the robust analyses, the pooled estimate of the treatment effect was significant.Furthermore, the effect of additional radiotherapy on 3-year progression-free survival  is shown in p < 0.000001) (NNT = 4). In the subgroup of studies comparing ICI-RT vs. ICI alone (245 patients), the association of RT with immunotherapy was associated with a statistically significant benefit in 3-year PFS (RR 0.89 (95% CI 0.80–0.99) p = 0.04) (NNT = 10). Two studies [p = 0.13). Two studies enrolled metastatic NSCLC [p = 0.07).Only one study compared ICI-RT vs. RT alone ,15 . Discontinuation of the study treatment because of adverse events occurred in 14.1% of the patients in the associated treatment group and in 8.6% of those in the single treatment. No statistically significant differences were found between the most frequent adverse events .p-values were 0.07 for 1-year OS and 0.13 for 3-year OS and 0.86 and 0.23 for 1- and 3-year PFS, respectively.Based on Begg’s test and Egger’s test for small-study effects, there was no publication bias. In Egger’s test, the According to the classical fail-safe N approach, 30 negative studies are required to nullify the effect of the association on 1-year overall survival and 32 on 3-year overall survival. Twenty-one studies are required to nullify the effect of the association on 1-year PFS, and 25 are required for 3-year PFS.Immunotherapy has been explored extensively in clinical trials as monotherapy for different solid cancers. For immune checkpoint inhibitors, combinatory use is still under investigation. A recent meta-analysis suggests that overall survival and progression-free survival in NSCLC can be improved by combination with other drugs, such as paclitaxel and carboplatin, dacarbazine, sargramostim, and the Gp100 vaccine . AnotherHence, this study investigated the key clinical question of whether adding RT to ICI could be more efficacious than ICI or RT alone in locally advanced or metastatic NSCLC patients.In this meta-analysis of literature data from 6 comparative studies analyzing 8435 patients, we found that ICI-RT improved 1- and 3-year overall survival versus ICI or RT alone. Furthermore, a pooled actuarial curve of OS was obtained  using CoRT with concurrent chemotherapy (CT) is the standard of care for the majority of patients with stage III NSCLC with radical intent. Additionally, in stage III NSCLC patients not eligible for radical treatment, an advantage in the survival of RT and CT has clearly been demonstrated ,25. In sConsidering the data available, we were able to systematically explore possible sources of heterogeneity using stratified analyses. Pooling studies with more than 20% of PD-L1 <1%, there is no change in the difference of outcomes. These findings are consistent with the results of two published studies ,15,16, sPooling studies with a rate of > 75%, the difference in 1- and 3- year overall survival and progression-free survival was comparable.The results of this retrospective analysis are subject to several limitations. Differences in the baseline severity of illness in the population of the studies, the irradiation dose and fractionation and the drug used may have limited the accuracy of this meta-analysis. These summary results describe variation only between studies, not between patients, because they reflect group averages rather than individual data. Lack of data on other potential confounders could also have affected the accuracy of the results. The meta-analysis was performed using summary data, and more detailed treatment comparisons could be achieved with a meta-analysis of individual patient data. Screening of the non-English literature and extensive manual and computer searches for studies made us confident that no important published trials were overlooked. A detailed assessment of the methodological quality of the included studies was performed; observational cohort studies were all of adequate quality. The study should ideally have been registered in a database such as PROSPERO before the study start to avoid research duplication, promotes transparency and help reduce potential for bias.Publication bias was probably not substantial and considered unlikely to change the direction of our pooled estimate of the treatment effect. We should be particularly concerned about publication bias in settings in which small studies are being conducted.The evidence from the literature data is sufficient to conclude the following: (1) the addition of immunotherapy to radiotherapy or immunotherapy alone improves 1- and 3-year overall survival; (2) progression-free survival is significantly influenced by ICI-RT association; and (3) gain in overall survival seems be retained in adenocarcinoma and PD-L1 negative patients.